Teaching Topic

Resuscitation

Original Article

Out-of-hospital cardiac arrest claims hundreds of thousands of lives each year worldwide. Successful resuscitation is challenging but achievable, requiring an interdependent set of actions that consist of early arrest recognition, early cardiopulmonary resuscitation (CPR), early defibrillation, expert advanced life support, and timely postresuscitation care.

Clinical Pearls

What is the potential advantage of chest compression alone for CPR?

Chest compression alone may be more acceptable to some laypersons and has the potential physiological advantage of fewer compression interruptions, so that circulation is increased, as compared with traditional CPR, although at a possible cost to oxygenation.

Was there any survival advantage between chest compressions alone and chest compressions with rescue breathing?

No. In this multicenter, randomized trial, CPR instructions consisting of chest compression alone did not increase the rate of survival to hospital discharge overall, as compared with instructions consisting of chest compression plus rescue breathing.

Morning Report Questions

Q. What was the overall rate of survival to hospital discharge among patients with cardiac arrest?

A. The authors observed no significant difference in the rate of survival to hospital discharge (12.5% for instructions to perform chest compression alone and 11.0% for instructions to perform chest compression plus rescue breathing, P=0.31) or the rate of survival to discharge with a favorable neurologic status (14.4% for chest compression alone and 11.5% for chest compression plus rescue breathing, P=0.13).

Q. Which group of patients appeared to have a better outcome when treated with chest compressions alone as compared to chest compressions with rescue breathing?

A. According to subgroup analysis, among patients whose arrest had a cardiac cause, there was a trend toward an increased rate of survival to hospital discharge (15.5%, vs. 12.3% for patients with other causes of arrest; P=0.09) and an increased rate of survival with a favorable neurologic status at discharge (18.9% vs. 13.5%, P=0.03) with chest compression alone.

Teaching Topic

Acupuncture

Clinical Therapeutics

Traditional Chinese medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body's vital energy, known as qi, which flows along 12 primary and 8 secondary meridians.

Clinical Pearls

According to traditional Chinese medicine, how is acupuncture thought to work?

The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi.

What pathophysiological phenomena have been identified in association with acupuncture?

Local anesthesia at needle-insertion sites completely blocks the immediate analgesic effects of acupuncture, indicating that these effects are dependent on neural innervation. Acupuncture has been shown to induce the release of endogenous opioids in brain stem, subcortical, and limbic structures. Acupuncture also causes effects on local tissues, including mechanical stimulation of connective tissue, release of adenosine at the site of needle stimulation, and increases in local blood flow.

Morning Report Questions

Q. What do the data from the most recent well-powered clinical trials of acupuncture conclude?

A. The most recent well-powered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients' beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.

Q. What guidance do the American College of Physicians and the American Pain Society provide for the use of acupuncture for chronic low back pain?

A. The American College of Physicians and the American Pain Society have issued joint clinical practice guidelines recommending that clinicians consider acupuncture as one possible treatment option for patients with chronic low back pain who do not have a response to self-care. The level of supporting evidence for this recommendation was characterized as fair.

quote of the week

"Dispatcher instruction consisting of chest compression alone did not increase the survival rate overall, although there was a trend toward better outcomes in key clinical subgroups. The results support a strategy for CPR performed by laypersons that emphasizes chest compression and minimizes the role of rescue breathing."

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